Scaling-up and scaling-out the Systems Analysis and Improvement Approach to optimize the hypertension diagnosis and care cascade for HIV infected individuals (SCALE SAIA-HTN): a stepped-wedge cluster randomized trial.

BACKGROUND: Undiagnosed and untreated hypertension is a main driver of cardiovascular disease and disproportionately affects persons living with HIV (PLHIV) in low- and middle-income countries. Across sub-Saharan Africa, guideline application to screen and manage hypertension among PLHIV is inconsistent due to poor service readiness, low health worker motivation, and limited integration of hypertension screening and management within HIV care services. In Mozambique, where the adult HIV prevalence is over 13%, an estimated 39% of adults have hypertension. As the only scaled chronic care service in the county, the HIV treatment platform presents an opportunity to standardize and scale hypertension care services. Low-cost, multi-component systems-level strategies such as the Systems Analysis and Improvement Approach (SAIA) have been found effective at integrating hypertension and HIV services to improve the effectiveness of hypertension care delivery for PLHIV, reduce drop-offs in care, and improve service quality. To build off lessons learned from a recently completed cluster randomized trial (SAIA-HTN) and establish a robust evidence base on the effectiveness of SAIA at scale, we evaluated a scaled-delivery model of SAIA (SCALE SAIA-HTN) using existing district health management structures to facilitate SAIA across six districts of Maputo Province, Mozambique. METHODS: This study employs a stepped-wedge design with randomization at the district level. The SAIA strategy will be "scaled up" with delivery by district health supervisors (rather than research staff) and will be "scaled out" via expansion to Southern Mozambique, to 18 facilities across six districts in Maputo Province. SCALE SAIA-HTN will be introduced over three, 9-month waves of intensive intervention, where technical support will be provided to facilities and district managers by study team members from the Mozambican National Institute of Health. Our evaluation of SCALE SAIA-HTN will be guided by the RE-AIM framework and will seek to estimate the budget impact from the payer's perspective. DISCUSSION: SAIA packages user-friendly systems engineering tools to support decision-making by frontline health workers and to identify low-cost, contextually relevant improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial will determine an effective strategy for national scale-up and inform program planning. TRIAL REGISTRATION: ClinicalTrials.gov NCT05002322 (registered 02/15/2023).

The Systems Analysis and Improvement Approach: specifying core components of an implementation strategy to optimize care cascades in public health.

BACKGROUND: Healthcare systems in low-resource settings need simple, low-cost interventions to improve services and address gaps in care. Though routine data provide opportunities to guide these efforts, frontline providers are rarely engaged in analyzing them for facility-level decision making. The Systems Analysis and Improvement Approach (SAIA) is an evidence-based, multi-component implementation strategy that engages providers in use of facility-level data to promote systems-level thinking and quality improvement (QI) efforts within multi-step care cascades. SAIA was originally developed to address HIV care in resource-limited settings but has since been adapted to a variety of clinical care systems including cervical cancer screening, mental health treatment, and hypertension management, among others; and across a variety of settings in sub-Saharan Africa and the USA. We aimed to extend the growing body of SAIA research by defining the core elements of SAIA using established specification approaches and thus improve reproducibility, guide future adaptations, and lay the groundwork to define its mechanisms of action. METHODS: Specification of the SAIA strategy was undertaken over 12 months by an expert panel of SAIA-researchers, implementing agents and stakeholders using a three-round, modified nominal group technique approach to match core SAIA components to the Expert Recommendations for Implementing Change (ERIC) list of distinct implementation strategies. Core implementation strategies were then specified according to Proctor's recommendations for specifying and reporting, followed by synthesis of data on related implementation outcomes linked to the SAIA strategy across projects. RESULTS: Based on this review and clarification of the operational definitions of the components of the SAIA, the four components of SAIA were mapped to 13 ERIC strategies. SAIA strategy meetings encompassed external facilitation, organization of provider implementation meetings, and provision of ongoing consultation. Cascade analysis mapped to three ERIC strategies: facilitating relay of clinical data to providers, use of audit and feedback of routine data with healthcare teams, and modeling and simulation of change. Process mapping matched to local needs assessment, local consensus discussions and assessment of readiness and identification of barriers and facilitators. Finally, continuous quality improvement encompassed tailoring strategies, developing a formal implementation blueprint, cyclical tests of change, and purposefully re-examining the implementation process. CONCLUSIONS: Specifying the components of SAIA provides improved conceptual clarity to enhance reproducibility for other researchers and practitioners interested in applying the SAIA across novel settings.

Current Practices and Nurse Readiness to Implement Standardized Screening for Commercially and Sexually Exploited Individuals in Emergency Departments in Western Washington Hospitals.

Approximately 80% of trafficked individuals access health care during their victimization. The emergency department is a frontline of care. This study examines current screening practices of Western Washington emergency department nurses to determine nurse and facility readiness for improved identification. Interviews were conducted with nurses to understand their current screening practices for identifying potential victims of sexual exploitation; the acceptability of existing screening questions for use in their settings; and their opinions about the utility of a standardized screening tool for identifying victims and improving care. There is an absence of formal protocols and screening tools, limited clarity regarding roles and responsibilities in the identification and care of trafficked persons among the health care team, and a desire to provide improved care quality to patients. Standardized processes and screening may lead to more efficient and effective identification of, care for, and linkage to vital support services and resources.

Primary Health Care Management Effectiveness as a Driver of Family Planning Service Readiness: A Cross-Sectional Analysis in Central Mozambique.

INTRODUCTION: The effectiveness of facility-level management is an important determinant of primary health care (PHC) reach and quality; however, the nature of the relationship between facility-level management and health system effectiveness lacks sufficient empirical grounding. We describe the association between management effectiveness and facility readiness to provide family planning services in central Mozambique. METHODS: We linked data from the Ministry of Health's 2018 Service Availability and Readiness Assessment and a second 2018 health facility survey that included the World Bank's Service Delivery Indicators management module. Our analysis focused on 68 public sector PHC facilities in Manica, Sofala, Tete, and Zambézia provinces in which the 2 surveys overlapped. We used logistic quantile regression to model associations between management strength and family planning service readiness. RESULTS: Of the 68 facility managers, 47 (69.1%) were first-time managers and (18) 26.5% had received formal management training. Managers indicated that 63.6% of their time was spent on management responsibilities, 63.2% of their employees had received a performance review in the year preceding the survey, and 12.5% of employee incentives were linked to performance evaluations. Adjusting for facility type and distance to the provincial capital, facility management effectiveness, and urban location were significantly associated with higher levels of readiness for family planning service delivery. CONCLUSIONS: We found that a higher degree of management effectiveness is independently associated with an increased likelihood of improved family planning service readiness. Furthermore, we describe barriers to effective PHC service management, including managers lacking formal training and spending a significant amount of time on nonmanagerial duties. Strengthening management capacity and reinforcing management practices at the PHC level are needed to improve health system readiness and outputs, which is essential for achieving global Sustainable Development Goals and universal health coverage targets.

Elevated CO2 affects anxiety but not a range of other behaviours in juvenile yellowtail kingfish.

Elevated seawater CO2 can cause a range of behavioural impairments in marine fishes. However, most studies to date have been conducted on small benthic species and very little is known about how higher oceanic CO2 levels could affect the behaviour of large pelagic species. Here, we tested the effects of elevated CO2, and where possible the interacting effects of high temperature, on a range of ecologically important behaviours (anxiety, routine activity, behavioural lateralization and visual acuity) in juvenile yellowtail kingfish, Seriola lalandi. Kingfish were reared from the egg stage to 25 days post-hatch in a full factorial design of ambient and elevated CO2 (~500 and ~1000 µatm pCO2) and temperature (21 °C and 25 °C). The effects of elevated CO2 were trait-specific with anxiety the only behaviour significantly affected. Juvenile S. lalandi reared at elevated CO2 spent more time in the dark zone during a standard black-white test, which is indicative of increased anxiety. Exposure to high temperature had no significant effect on any of the behaviours tested. Overall, our results suggest that juvenile S. lalandi are largely behaviourally tolerant to future ocean acidification and warming. Given the ecological and economic importance of large pelagic fish species more studies investigating the effect of future climate change are urgently needed.

Ocean warming has a greater effect than acidification on the early life history development and swimming performance of a large circumglobal pelagic fish.

Ocean warming and acidification are serious threats to marine life; however, their individual and combined effects on large pelagic and predatory fishes are poorly understood. We determined the effects of projected future temperature and carbon dioxide (CO2 ) levels on survival, growth, morphological development and swimming performance on the early life stages of a large circumglobal pelagic fish, the yellowtail kingfish Seriola lalandi. Eggs, larvae and juveniles were reared in cross-factored treatments of temperature (21 and 25°C) and pCO2 (500 and 985 µatm) from fertilisation to 25 days post hatching (dph). Temperature had the greatest effect on survival, growth and development. Survivorship was lower, but growth and morphological development were faster at 25°C, with surviving fish larger and more developed at 1, 11 and 21 dph. Elevated pCO2 affected size at 1 dph, but not at 11 or 21 dph, and did not affect survival or morphological development. Elevated temperature and pCO2 had opposing effects on swimming performance at 21 dph. Critical swimming speed (Ucrit ) was increased by elevated temperature but reduced by elevated pCO2 . Additionally, elevated temperature increased the proportion of individuals that responded to a startle stimulus, reduced latency to respond and increased maximum escape speed, potentially due to the more advanced developmental stage of juveniles at 25°C. By contrast, elevated pCO2 reduced the distance moved and average speed in response to a startle stimulus. Our results show that higher temperature is likely to be the primary driver of global change impacts on kingfish early life history; however, elevated pCO2 could affect critical aspects of swimming performance in this pelagic species. Our findings will help parameterise and structure fisheries population dynamics models and improve projections of impacts to large pelagic fishes under climate change scenarios to better inform adaptation and mitigation responses.

Reduced description of complex dynamics in reactive systems.

Detailed chemical kinetics typically involve a large number of chemical species and a wide range of time scales. In calculations of chemically reactive flows, dimension-reduction techniques can be used to reduce the computational burden imposed by the direct use of detailed chemistry. In the reduced description, the reactive system is described in terms of a smaller number of reduced composition variables (e.g., some "major" species) instead of the full set of chemical species. Reactive flows exhibiting complex dynamics are especially challenging for dimension-reduction techniques and therefore provide more rigorous validation for such methods. Following the work of Brad et al. [Proc. Combust. Inst. 2007, 31, 455],1 in this paper, we demonstrate the capability of the Invariant Constrained-equilibrium Edge Pre-Image Curve (ICE-PIC) dimension-reduction method [J. Chem. Phys. 2006, 124, Art. No. 114111]2 through calculations of the oxidation of a CO/H2 mixture in a continuously stirred tank reactor (CSTR) at low pressure. The detailed chemical kinetics employed involves 11 species and 33 reactions. The system exhibits complex dynamics such as oscillatory ignition, oscillatory glow, and mixed mode oscillations. It is demonstrated that with five represented species the reduced description provided by the ICE-PIC method is able to quantitatively reproduce the observed complex dynamics. Moreover, the reduced description accurately predicts the boundaries of slow reaction, oscillatory ignition and the steady ignited state.

The invariant constrained equilibrium edge preimage curve method for the dimension reduction of chemical kinetics.

This work addresses the construction and use of low-dimensional invariant manifolds to simplify complex chemical kinetics. Typically, chemical kinetic systems have a wide range of time scales. As a consequence, reaction trajectories rapidly approach a hierarchy of attracting manifolds of decreasing dimension in the full composition space. In previous research, several different methods have been proposed to identify these low-dimensional attracting manifolds. Here we propose a new method based on an invariant constrained equilibrium edge (ICE) manifold. This manifold (of dimension nr) is generated by the reaction trajectories emanating from its (nr-1)-dimensional edge, on which the composition is in a constrained equilibrium state. A reasonable choice of the nr represented variables (e.g., nr "major" species) ensures that there exists a unique point on the ICE manifold corresponding to each realizable value of the represented variables. The process of identifying this point is referred to as species reconstruction. A second contribution of this work is a local method of species reconstruction, called ICE-PIC, which is based on the ICE manifold and uses preimage curves (PICs). The ICE-PIC method is local in the sense that species reconstruction can be performed without generating the whole of the manifold (or a significant portion thereof). The ICE-PIC method is the first approach that locally determines points on a low-dimensional invariant manifold, and its application to high-dimensional chemical systems is straightforward. The "inputs" to the method are the detailed kinetic mechanism and the chosen reduced representation (e.g., some major species). The ICE-PIC method is illustrated and demonstrated using an idealized H2O system with six chemical species. It is then tested and compared to three other dimension-reduction methods for the test case of a one-dimensional premixed laminar flame of stoichiometric hydrogen/air, which is described by a detailed mechanism containing nine species and 21 reactions. It is shown that the error incurred by the ICE-PIC method with four represented species is small across the whole flame, even in the low temperature region.